Did the Affordable Care Act make the grade?

Four years since health care reform became law, there is finally enough information
to grade how well enrollment is going. It will be many more years before the program
can be judged an overall success, however.

Although it is now more than 4 years since it first became law, it is only with the
end of the Affordable Care Act (ACA's) first annual open enrollment period on April
15 that we can begin to get a real sense of its impact. Of course, there is still
a long way to go and many more years of tracking enrollment before one will be able
to definitively declare that the ACA has been an overall success, failure, or something
in between. Still, at the risk of going a bit out on a limb, I think there is enough
information to begin to grade how well the ACA's enrollment is going—so far,
that is.

Total enrollment in qualified health plans: A

The number of people who signed up for a qualified health plan exceeded 8 million
people when the first-year enrollment process closed on April 15, more than 1 million
more than the Congressional Budget Office had estimated before the botched launch
last October (more on the launch later). This number is expected to increase because
several states running their own insurance marketplaces (also known as exchanges)
gave people a few more weeks to complete enrollment. Also, people whose circumstances
change during the year, like a woman having a baby, can still choose a qualified plan
through a special enrollment process.

Total enrollment in Medicaid and CHIP (federal government): A

Because of the ACA, another 5.23 million to 7.29 million low-income people had enrolled
in these programs by mid-April. But unlike the marketplace health plans, eligible
persons can continue to sign up for Medicaid and the Children's Health Insurance Program
any time during the year, so these numbers will increase.

Total enrollment in Medicaid and CHIP (the states): A for states that have expanded
Medicaid; F for states that haven't

When the Supreme Court declared the ACA's original requirement that states expand
Medicaid unconstitutional, while upholding the rest of the law, it left it up to the
states to decide if they would expand the program. Twenty-six states and the District
of Columbia have said yes; the rest have not (although some are still thinking about
it).

Under the ACA, the only way that people with incomes below the federal poverty level
can get covered is through Medicaid, so if you are a poor person who lives in a state
that has turned down the expansion, you are left out in the cold. According to an
April 4 Washington Post article, enrollment in Medicaid since September “grew 8.3% in states that expanded
their programs for low-income residents, 5 times higher than the 1.6% enrollment increase
that non-expansion states saw over the same time.”

Reducing the number of uninsured (nationwide): B+

Although we don't have exact numbers yet, the Rand Corporation estimated that more
than 9 million previously uninsured people have gotten coverage so far this year.
The Congressional Budget Office estimates that this will grow to 12 million by the
end of 2014. The Gallup Organization found that “The uninsured rate has been
falling since the fourth quarter of 2013, after hitting an all-time high of 18.0%
in the third quarter—a sign that the Affordable Care Act, commonly referred
to as ‘Obamacare,’ appears to be accomplishing its goal of increasing
the percentage of Americans with health insurance coverage.”

Reducing the number of uninsured (the states): A for states that are on board with
the ACA, F for states that are not

Gallup also found that “The uninsured rate among adults aged 18 and older in
the states that have chosen to expand Medicaid and set up their own exchanges in the
health insurance marketplace has declined significantly more this year than in the
remaining states that have not done so.”

Initial ACA rollout, October through November: F

I won't sugar coat it. The initial botched rollout and nonworking healthcare.gov portal were a disaster for the ACA, for the administration, and for anyone who wanted
the ACA to succeed.

ACA rollout, December through April: A

I had my doubts that they could pull it off, but the administration did manage to
get the website working and, with a lot of help from others, persuaded millions of
Americans to sign up.

Handling of canceled insurance policies: D

The administration knew all along that a small percentage of people, about 3% of the
population, would have to replace their individual insurance plans with one that meets
the ACA's coverage requirements. But the 12 million or so people who were affected
did not see it coming, and when the cancellations became front-page news, the administration
was ill-prepared to respond and then kept changing the rules. The president's promise
that “you can keep your plan if you like it” was proven to be untrue
for them.

But now it turns out that more than 70% of this group qualified for the ACA's premium
subsidies, and the Rand Corporation estimates that fewer than 1 million of them were
still without coverage by mid-April.

Protection for people with preexisting conditions: A+

This one is simple. Because of the ACA, no one can be turned down or charged more
because they have a preexisting health condition.

Network adequacy and benefits: C

Because of the ACA, Americans can't be sold an insurance plan that fails to cover
10 categories of essential benefits, and prevention is covered at no cost. But many
of the plans sold have high deductibles and/or very narrow “provider”
networks and restrictive formularies, which can undermine the ACA's goal of making
affordable care available to everyone. ACP has argued that the administration and
state regulators need to do a better job of regulating network adequacy and formularies.

Cumulative ACA enrollment grade: ?

It depends on where you live. If you live in a state that's on board with the ACA (Medicaid and exchanges), your
state's effort, combined with the federal government's implementation, earns a B,
a very good grade for an immensely complicated law. But if you live in a state opposed
to Medicaid expansion and the marketplace plans, the grade is D, because your state
is standing in the way of people getting covered and there is little that the federal
government can do about it.

Overall, though, the ACA deserves high marks for expanding coverage to millions. Let's
hope that by next year, more states will have made the grade by expanding Medicaid
to their poorest residents.

Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. ACP Internist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.